Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

Monday, November 30, 2009

Writing the blog is sometimes very painful. It’s not because I don’t like to write, because I do. It’s not because it’s difficult, although I do agree with the fictional author in The Angel’s Game who notes that sometimes to write you just have to sit down, squeeze your brain, and see what comes out.

The writing is painful because I can’t tell you the stories I really want to tell.

The good stories, the real stories, the stories worth telling in medicine are not the ones I write for you. The ones you see are the easy ones. They are the stories with set beginnings and endings, stories with no harm and no foul. They are stories that live in a world of black and white, a world where things are both defined and definite, and where thought is not required but is nice work if you can get it.

That’s not the real world of emergency medicine, at least not where the good stuff lies. The world that’s interesting , challenging, where souls are searched, doubts are harbored, and sleep is lost is a world of grays where the edge of the knife is often unseen and days of sheer boredom are punctuated by moments of utter madness. It’s a world of maybes and possiblys, of probablys and I-don’t-think-so’s, a world where every step into the subjective morass we call humanity is haunted by thoughts of doing too much and what we might miss. It’s a world where things just happen, and whether you do or don’t do something about it seems to make no difference at all. It’s a world where people die for no explicable reason, and where people who should be dead, or need to be, aren’t.

The best medical writing in ages past dealt with these very issues. Especially in the days before effective therapy, physicians would write about the real practice of medicine, about comforting the hopeless, trying to make sense of suffering, standing alone against tidal waves of uncertainty, plunging into the unknown chasm between science and faith. But the reader trying to understand the practice of medicine in our times will find nothing but tales of difficult but successful cases, lots of thoughts on the business of medicine, and a slew of soulless technical reports.

The reason is that it’s just become too dangerous to put reality into words. We live in a society where everything is foreseen through hindsight, and where the mists of time do nothing but sharpen the view. We’ve done such a good job advertising medical advances that nothing less than perfection is accepted; if something happens, it must be someone’s fault. And while we may acknowledge that nature may have her whims, we still cast about for someone to blame for her damage. (I think ED folks have an inherent understanding of nature’s victories. We know that when it’s car versus tree, the tree always wins…even if it’s been turned into a telephone pole.)

So why can’t I write the stories I want to tell? It’s because I’m scared to do so. Terrified, in fact. If I tell you these stories, I have no way to know that someone won’t pick up on the tale and trace it back to a patient. Within medical culture, judgment calls are automatic reasons for criticism. Indeed, there’s a whole academic industry called the Morbidity and Mortality Conference in which physicians who have never actually seen the patient nor work in the same field roundly dissect the care provided by another doctor. There’s also the system of Peer Review, which seems much less concerned with improving care than finding someone to take the fall for failures of the health care system. And that’s not even talking about the medicolegal climate, where anything is fair game for a lawsuit and there’s always an expert to tell you you’re wrong. (I say this as someone who’s done expert witness case review). A clinical tale might be traced back to an actual incident, and what is intended as an expression of the real challenges of care becomes ammunition for an assault on my integrity and my livelihood.

So I probably will never be able to write the kind of stories I really want to, at least until the statue of limitations runs out and I’m truly retired for good with all my assets in trust. Until then, continue to enjoy the pieces of fluff I put out. You’ll never really know what you’re missing.

Friday, November 27, 2009

I’ve never been able to agree with those who contend that health care should operate strictly along free market principles, and that allowing it to do so without government involvement or competition is the best way to promote health care reform. I don’t believe this because it’s never worked that way before, and the very nature of health care precludes it from operating as a free market entity.

The fact is that you can't look at health care as a marketplace subject to the same market forces as buying a home appliance. The key difference is that health care is accessed differently than other markets. For example, it’s your insurance plan that often dictates your choice of physician or hospital, not your informed consumerism. Your insurance plan may not be your choice, but the only one offered to you by your employer or the government. If your needs are urgent, your choices are often circumscribed by time, geography, and the need for specialty services. The vast majority of expenditures on your behalf go through a single gatekeeper (your personal physician) rather than an individual having free choice of costs, products, and options to review at their leisure. I don't know that I can support the idea of heath care operating as a pure free market system, not because there's anything wrong with the free market, but because health care cannot by its very essence operate in that way except in a very limited realm of choices and services. An employer choosing which health plan to offer employees can do so using free market principles; the employee's use of that policy cannot.

But health care can work as a free market for those procedures that are purely elective, like cosmetic plastic surgery. There was a time in medical school that I wanted to be a plastic surgeon. It was during my first year, when we were rotated through community hospitals for the purposes of getting acquainted with clinical medicine. (In reality, it was an excuse for the University to charge us a whole lot more money for the privilege of wearing a lab coat once a week and pretending you were something other than a rank freshman dissecting preserved cats in biology class.) By chance, I was taken in by Dr. Michael Hynes, a plastic surgeon in Kansas City. He would let me watch surgery and follow him during rounds, all heady stuff for a teenager.I still remember the first surgery I ever got to scrub on. It was an amputation of the lower leg for persistent problems with circulation and non-healing wounds, and he had asked my friend Todd Gwin and I to assist. Our “help” had consisted on holding the leg down by the ankle while he worked some kind of surgical magic just above the knee. We were watching him, fascinated by what he was doing but not yet with enough knowledge to actually figure it out, when he quietly said, “Okay, take that leg and hand ot off to the nurse.”

Todd and I looked at each other in the space between our surgical masks and our scrub caps.

“Huh?”

“Yeah, take it off the table and put it on the cart behind you.”

What we hadn’t realized is that he had just detached the lower leg from the rest of the body. Looking at each other with disbelief and a trace of fear, we slowly started to lift the leg up and could not understand why the rest of the limb from the knee up didn’t come with it. We thought that maybe we had just not lifted it high enough, but not matter how many inches we took the leg above the table the rest of the body stubbornly refused to come along for the ride. And then we were holding this disembodied, waxy leg, now cool to the touch with it’s blood supply severed, looking at it with utter disbelief and in total ignorance of what we should do with it.

“Taking it away today would be good.” Dr. Hynes stayed bent over his work.

So as the rolling table was on my side, Todd shifted to weight of the leg to me. While nurse aides and other caretakers have a keen sense of what it feels like to lift the dead weight of an adult human body, most of us really have no idea. We pick up molded plastic bloodied limbs at the Halloween store to decorate our homes and think it’s something like the real thing. The truth is that the human body is heavy and awkward, that the sprawling limbs and floppy head defy all the rules for lifting weights as a consolidated compact mass. This is all a polite way of saying that I had no idea how much a human leg weighed, and I almost dropped it. By the time I had gotten it over to the cart, I recognized that I should have some kind of profound thought, but nothing came to me except a very clinical, “Whoa, that’s a leg.” Which, I suppose, is precisely the point.

Dr. Hynes was a great guy. While he may have done lots of cosmetic work, most of what I saw was reconstructives…facial fractures, skin flaps, rebuilding pieces and parts. I thought it was fascinating (still do), and that this was what I wanted to do for a living. That was, until I learned that in order to become a plastic surgeon I would have to voluntarily submit to five years of butt-whipping and genital-licking to be a top general surgery resident, and then try to weasel my way into two additional years of the same as a plastics fellow, and suddenly three years of shift-based, not-on-call Emergency Medicine residency seemed a much better deal. And while the ER has been a great ride, that’s still one career decision I regret.

But back to the free market, the glories of capitalism, and the shameless pursuit of ersatz perfection. The hospital where I work will be placing an advertisement in the November 30th issue of the Daytona Beach News-Journal. Entitled “Ten Procedures Specially Priced for the Holidays: ‘Tis the Season for a New You,” it pictures a gingerbread man complete with a list of elective plastic surgical procedures and prices, with arrows pointing to the relevant part of the pastry individual. A facelift is $4,000, and new nose is $2,800, and a mere $3,000 gets your ears pinned back to the sides of yur head. (Interestingly, the most common plastic surgical procedure performed on gingerbread people...dental dismemberment and decapitation, or biting off the arms, legs, and head…is actually not listed as an option, probably because it’s free.) The ad mentions that gift certificates for these procedures are great stocking stuffers, because there is nothing more your beloved wants than a gift that says there’s something fundamentally wrong with you and I’m willing to pay real money to make it go away.

(I showed the ad to a friend of mine who actually is a plastic surgeon. He looked at the picture, thoughtfully pulled down his glasses down over his nose, and with all professional seriousness noted, “$2,920 is pretty good for a couple of decent breasts.”)

It took little effort to think through the ramifications of this proposal. Take the breasts. The line from the printed price to the appropriate part of the gingerbread man pointed to a single red hot where the right breast would be. (Since the gingerbread man also had a bow tie, we’re still a little confused about the gingerbread gender.) So the first question to answer is if the price was for a single breast, because that’s what it pointed to, or for a set of two. And then we wondered what kind of breasts you got for $2,920. Saline or silicon? Paper or plastic? Mix and match?What about size? Was that the full price to go from A to DD, four sizes up? If you only wanted to go up two sizes, say from a C to a DD, is it only have the price? And why was the price an odd number, like $2,920? If you spent the extra $80 and made it an even $3,000, did you get some kind of bonus item like an extra nipple?

(I don’t have any really good plastic surgery breast stories. The only one worth telling is the time I was out with friends, everyone got a little drunk, and one of our more generously endowed nurses decided it would be educational for us to see just how good a job her plastic surgeon had done on her breasts. So she flashed, and I looked, and the pathetic combination of age, alcohol, and clinical acumen in me meant that I actually was noticing the exemplary symmetry and the lack of obvious scarring rather than the intended humongous perkiness of the effort.)

I do think sales like these are a good idea, and not just because they help jump-start the local economy. I know that personally, when I was “on the market,” as it were, I could easily spend at least this much money in meals, movies, and jewelry just trying to get a good long look at a single set of breasts. Imagine spending the same amount of money, and then getting to own them? What a deal! That is, as long as they don’t run off with the undercarriage.

Monday, November 23, 2009

The hospital where I work has been conducting a series of seminars designed to enhance the patient and family experience at our facility. The effort is motivated by several factors. One is certainly to support the hospital’s mission as a place of care and comfort for the community. However, because health care is now very much a business, there are other, less altruistic reasons for doing so. In a competitive marketplace, the facility where patients and families feel most comfortable has the opportunity to take more of the market share of work. And the federal government is compiling data regarding customer satisfaction with health care facilities through the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (H-CAHPS). The stated goals for the survey are for public reporting to enhance the transparency of care and provide incentives for hospitals to improve their performance. But the unspoken bottom line is that at some point in the future, scores will be used to modify reimbursement patterns. This concern makes it key for facilities and their employees to understand the H-CAPHS system and align themselves in such a way as to insure that scores are as high as possible.

So last month off I went to my scheduled session at 0730 (it sounds more important in military time) after working a particularly nasty night shift. Fortified with two cups of hot tea, I found a place in the back of the room where I figured I could hide when the lights went down and the Sandman stopped by for his imminent a visit. I was careful to choose a spot beneath an air conditioning vent as well, for I’ve learned over time that the sound of air blowing through the ductwork can mask all but the most sonorous respirations.

(This meeting-sleeping parallel is not new to me. During medical school, the daily Noon Conference was held in a large amphitheater with raised tiers surrounding a central dais. Each tier featured a continuous desk with a lowered skirt that extended along the perimeter of the tier facing the speaker. Behind the desks were swivel chairs attached to the table legs. What this meant in practice was that when the theater was full…which it always was because 1) attendance was required and 2) attendance was required…is that you could lay down on the floor on the uppermost tier and take a nap completely blocked from view by anyone except the three people sitting in the chairs just above your head. I took full advantage of this fact every day for the two months of my annual internal medicine rotation. This skill was not unnoticed by my classmates, who awarded me the “Rip Van Winkle” Award three years in a row. To date, I am the only repeat winner in the history of the school.)

The first order of business was to fill out a name sticker with the one word that describes how you felt at that very moment. Being a generally truthful sort, I wrote TIRED in large capital letters. Turns out that was the wrong answer, and I earned a reproach from the trainers who oozed early-morning glee in a pathologically perky manner. (I’m still working out exactly which organ exudes glee.) It turns out that the correct answer was HAPPY or ENTHUSED or BLESSED, and if I had been thinking I could have applied these words equally well. I was indeed HAPPY to be off shift, and ENTHUSED to be going home, and BLESSED by the fact that case management workers exist to find nursing homes for patients in the middle of the night.

The centerpiece of the presentation was motivational video that I’ve seen several times before. It’s been making the corporate rounds, so perhaps you have too. It’s the one about workers at the Pike Place Fish Market in Seattle who make a cold, nasty job into something fun by laughing, joking, shouting, and flinging fish into the air. The point of the video is that you choose your attitude towards you job. In theory, this works well. In practice, however, it’s a bit more difficult to pull off. During one of my stints as a bureauocrat we decided we would enhance our workplace by tossing file cabinets as a teamwork game. Windows were broken, alarms went off, and the local police did not seem like we had made their job any more fun. (I think they just chose the wrong attitude, but given that law enforcement officers can singlehandedly ruin my car insurance rates they can choose any attitude they want and it’s perfectly okay with me, sir or ma’am.)

The group was then invited to talk about ways they can make work fun. I apparently was called on to proffer a suggestion, and I must have said something. The truth is that I was so tired I have no idea if I did or not. I recall watching the fish soar through the rainy skies of the Pacific Northwest, and then I was seeing a packet of crackers in front of me just before a red squeezey trinket careened off my head. It must have been a “carrot-and-stick” sort of thing.

Another party favor I got to take home was a pre-printed card to remind me that “Kindness is Contagious.” Having been indoctrinated throughout medical training that contagious things ought to best be stamped out as quickly as possible, I’m still working through this concept. I also received some notecards that I’m supposed to give to someone when I see them do something of particular value to the health care team. I’ve already pre-written a few, such as “Thanks for graciously cleaning up that bodily fluid spill last night. Lord knows I wasn’t gonna touch that,’ and “I appreciate your kind and considerate help in cold-cocking the patient who came at me with a stick.”

In the end, a good time was had by all, and I was able to go home and rest with my free package of snack crackers and the soft plastic squeezy thing which the Residential Cat promptly took apart. Tomorrow before my shift I’m going down to Hull’s Fish Market and getting three pounds of mullet. If throwing one big fish around is good for morale, imagine the effect of forty smaller ones. It’s a way to spread the joy even farther. Especially if I hide them in various places where they won’t be found for a few days. Just think of what that’ll do for morale!

Saturday, November 21, 2009

The National Institute on Drug Abuse, a division of the National Institutes of Health, gave Nabi BioPharmaceuticals a $10 million grant to take its anti-nicotine vaccine, NicVAX, to clinical trials. Officials want to confirm its effectiveness, monitor side effects, compare it to commonly used treatments and collect information that will allow the drug treatment to be used safely…

NicVAX is designed to stimulate the immune system to create antibodies that latch onto nicotine molecules in a smoker's bloodstream, preventing nicotine from entering the brain. Trapped outside the brain, the too-large molecules of nicotine can’t trigger the addictive pleasure chemicals invoked by smoking tobacco. …

The results of initial trials on 1,000 patients has been promising and caused few side effects. Nabi BioPharmaceuticals reports that 35 percent of those given the vaccine have been able to remain smoke-free compared with only 10 percent of patients who received a placebo.

(Nicole Straff, AOL Health, November 13, 2009)

I’ve written previously on The Blog about the benefits of vaccinations, and about the need for patients to assume some degree of responsibility for their own health behaviors. So when I read the on-line notice as I sipped my early morning Dunkin’ Donuts Vanilla Chai (Note to Company: Why can’t I get any size larger than medium?), my interest was piqued. The idea of a vaccine for nicotine addiction, and the use of a quick technological fix to prevent the health effects of cigarette use, appealed to every public health bone in my body. (Admittedly, these moments are getting fewer and fewer as I get farther from that phase of my life. Yet every now and then one of these residual ossicles lodges in my throat and I have to resort to the Heimlich Maneuver of Public Concern to get it out.)

Pharmacologic therapy for addictions is not a new idea. There are lots of therapies out there to help manage acute overdoses of medications such as narcotics (Codeine, Lortab, and Percocet) and benzodiazepines (Valium and Ativan). There are also a host of treatments to help manage both narcotic and alcohol withdrawal symptoms, and specific pharmacologic regimens have been developed to provoke acute withdrawal in a supervised setting under sedation or anesthesia to speed up the detoxification process. (This is actually a pretty good business as well; an outfit in Michigan offers a one hour detox under anesthesia for only $6,700. The on-line brochure notes that operators are available 24 hours a day, 7 days a week. And of you order now, we’ll throw in the Showtime Rotisserie Oven and this amazing spiral slicer. Call today!)

Less common, however, are medications that are given on the front end to inhibit the addictive behavior. Many people are familiar with the fact that heroin addicts are often treated with methadone, an artificial analogue of the street drug prescribed by a physician. In theory this takes the addict off the street and facilitates a slow and gradual withdrawal; in reality, it substitutes one addictive drug for another, and while it does take folks off the street it puts them into the ED on nights and weekends when the Methadone Depot is closed. (True story: About three months ago I was working a night shift and the police brought in an empty shipping carton containing twelve one liter bottles of methadone elixir. But it’s not addictive, right?). There are implants that can provide some assistance by blocking the effect of opiates as well, but their long-term success in preventing recidivism is not yet established. And while certain antidepressants (Chantix) have been used to assist with smoking cessation, it’s uncertain whether their effect is really related to the antagonism of nicotine or on managing the mild situational depression that often accompanies attempts at lifestyle change.

There is also a medication out there to prevent alcohol abuse. It’s called disulfiram (Antabuse), and its use was quite the rage when I was in training. What it does is block the metabolism of alcohol so when a person taking the drug uses alcohol, there’s a buildup of acetaldehyde formaldehyde in their system. Acetaldehyde is the main ingredient of a hangover, and the patient who swigs a beer while on the drug has an immediate (5-10 minute) and quite potent hangover complete with sweating, shaking, flushing, nausea, violent retching, and a feeling of being generally unwell (I use that term because I’m not sure “crappy” is a word befitting medicine, and I can’t in good conscience refer to a bowel-product in a family publication.) Recall that the closely related formaldehyde is the stuff they use to pickle dead fish and fetal pigs in jars on the wall in high school biology, and you can figure that you probably don’t want any of that in you. Disulfiram isn’t used much anymore. The official reason is that there are so many products with alcohol in them (mouthwash, liquid medications, etc), that patients were inadvertently pushed into reactions, which was admittedly unfair to them. However, my own theory is that nobody takes it anymore because it stops alcoholics from drinking, and if I’m an alcoholic the last thing I’m going to do is take something that going to make me sick when I drink. In my experience, most alcoholics would like to have their hangover the old-fashioned way, so compliance with Antabuse is usually abysmal. Personally, I wish it would make a comeback, and specifically that they would develop an injectable form for use in the ED. I can’t help but think that if we could induce a violent hangover in some of our more chronic alcoholic patients rather than just letting them sleep it off, they might be more motivated for treatment.

(To be frank, there are other examples of punitive theory in which I fervently believe. For example, gonorrhea can be treated equally well with either a painful injection in the posterior or with a dose of oral medication. If you’re the one passing the disease around, or if you’re just being a jerk, guess which therapy you get?).

But there’s never been a vaccine that regulates behavior leading to long-term health problems. The concept is fascinating. By blocking the passage of nicotine through the blood-brain barrier, we stop the stimulation of nicotine receptors in the brain. If the receptors are blocked, there’s no pleasure from smoking. The idea opens the door to a world of possibilities. Can we do the same for the metabolic products of alcohol, preventing them from affecting the brain and blocking the pleasant feelings of Cap’n Jack? How about narcotics? A biochemical stimulant that produces obesity? Sound waves at the frequency of Glenn Beck’s voice?

Like most things, the idea of a vaccine against behavior is easier said than done. This use of technology also opens up an entire spectrum of ethical issues. Let’s say that we are, in fact, able to regulate behavior with vaccines. Do we want to? Is it right to do so? How do you give informed consent for behavioral change when the end result may be permanent? What does it do to the concepts of autonomy and free will? And as our knowledge of immunology and neurochemistry gets more specific, can we develop vaccines to block other behaviors not related to poor health? I don’t know that I’d go as far as to invoke George Orwell’s 1984, but it’s pretty easy to see where the argument is headed. Clinically, there’s a problem here as well. It’s entirely possible that a drug addict who got an anti-narcotic vaccine has a broken leg six months later. Even I’d be hard pressed to say that the patient should be denied the beneficial effects of pain medication simply because the vaccine is already “on board” and doing its stuff. (I think the people I work with would tell you I’m a relatively hard person to get narcotics from, but I do have my limits. My theory has always been if you break something, lose something, bleed somewhere, have cancer, or let me stick a sharpened piece of stainless steel somewhere into your body, you can have all the pain medication you want.)

There’s also a flip side to the coin. Vaccines designed for clinical purposes can be perceived as facilitating undesirable behavior. We’ve seen this with the advent of the Human Papilloma Virus (HPV) vaccine. Clinically, this is great thing. We know that cervical cancer is a leading killer of young women, and that cervical cancer is caused in large part by infection with HPV. HPV, in turn, is fairly ubiquitous in our society, so it makes sense to offer the HPV vaccine to all girls and young women in order to diminish their risk of cancer. While there are still some issues to work out…namely if there are long-term effects, and if boys who are carriers of HPV should get vaccinated as well…this is a wonderful innovation and the first in what we hope will be a virtual cornucopia of preventive immunotherapies for malignant disease.

How can something this good get tuned on its head? Well, HPV is contracted through sexual contact. And if we make unprotected sex safer, that might encourage more teenagers and unmarried people to have sex. That’s not right. And if that happens, there might be more abortions. That would also be wrong. Clinically, I would argue (and have done so) that while it’s true that there may be less risk of cervical cancer, there are still plenty of other reasons to discourage sex outside of a long-term monogamous relationship. Things like unwanted pregnancy, gonorrhea, syphilis, hepatitis, and AIDS come to mind. But you can see the politics at work here, can’t you?

In the long run, I suspect the story of the nicotine vaccine (at least the form currently in trials) will be a lot like the tale of the gastric banding procedure. The “fatpass” (official medical term) decreases the size of the stomach so less food can be taken in at each meal, therefore decreasing total caloric intake and inducing weight loss. That being said, I’ve seen hosts of patients who had the procedure and, after initially losing poundage in the triple digits, have put most of it right back on. This happens because their underlying issues with food and lifestyle cannot be solved with surgery, and so they learn to compensate for the procedure by eating the same volume of food, but eating smaller amounts more frequently. (One of my ED doc colleagues is a perfect example of this. The day after his gastric bypass, someone called to see how he was doing. He was eating a pan of brownies, but with the bypass he could only eat them only one at a time.)

The article described a success rate of 35% in getting patients to remain nicotine-free. Checking out the company’s web site, the trials have lasted only 6-12 months. And while a short-term return of 35% is surely better than nothing, it’s still only 35%. People who are successful with permanent weight loss after gastric bypass surgery are those who also change their diet, lifestyle, social circles, and self-perceptions. If the vaccine helps only a minority of smokers to quit, there must be a host of other reasons for tobacco use besides the nicotine kick. While the vaccine can be part of the solution…and if it passes clinical trials, I’ll be proud to be a cheerleader…it is a single piece of the puzzle which also includes higher prices on tobacco products, clean indoor air legislation, enforcement of underage tobacco purchases, expansion of smoking cessation programs, and public education. My fear is that in this technology-happy, quick-fix society, those strategies shown to have real impact on the health effects of tobacco use will be lost.

Thursday, November 19, 2009

After the serious stuff, and two very tiring ED shifts, I will freely admit to cheating on today's post. I got this from The Father with an infinite email trace, so nobody knows where it started...but I hope you think it's as funny as I did!

You have to be old enough to remember Abbott and Costello, and too old to REALLY understand computers, to fully appreciate this. For those of us who sometimes get flustered by our computers, please read on...

If Bud Abbott and Lou Costello were alive today, their infamous sketch, 'Who's on First?' might have turned out something like this:

COSTELLO CALLS TO BUY A COMPUTER FROM ABBOTT

ABBOTT: Super Duper computer store. Can I help you?

COSTELLO: Thanks I'm setting up an office in my den and I'm thinking about buying a computer.

ABBOTT: Mac?

COSTELLO: No, the name's Lou.

ABBOTT: Your computer?

COSTELLO: I don't own a computer. I want to buy one.

ABBOTT: Mac?

COSTELLO: I told you, my name's Lou.

ABBOTT: What about Windows?

COSTELLO: Why? Will it get stuffy in here?

ABBOTT: Do you want a computer with Windows?

COSTELLO: I don't know. What will I see when I look at the windows?

ABBOTT: Wallpaper.

COSTELLO: Never mind the windows. I need a computer and software.

ABBOTT: Software for Windows?

COSTELLO: No. On the computer! I need something I can use to write proposals, track expenses and run my business. What do you have?

ABBOTT: Office.

COSTELLO: Yeah, for my office. Can you recommend anything?

ABBOTT: I just did.

COSTELLO: You just did what?

ABBOTT: Recommend something.

COSTELLO: You recommended something?

ABBOTT: Yes.

COSTELLO: For my office?

ABBOTT: Yes.

COSTELLO: OK, what did you recommend for my office?

ABBOTT: Office.

COSTELLO: Yes, for my office!

ABBOTT: I recommend Office with Windows.

COSTELLO: I already have an office with windows! OK, let's just say I'm sitting at my computer and I want to type a proposal. What do I need?

ABBOTT: Word.

COSTELLO: What word?

ABBOTT: Word in Office.

COSTELLO: The only word in office is office.

ABBOTT: The Word in Office for Windows.

COSTELLO: Which word in office for windows?

ABBOTT: The Word you get when you click the blue 'W'.

COSTELLO: I'm going to click your blue 'w' if you don't start with some straight answers. What about financial bookkeeping? You have anything I can track my money with?

Wednesday, November 18, 2009

Yesterday I mentioned a new CMS report noting that the current health care reform proposals that have passed the House of Representatives would improve coverage, but increase costs. While that undoubtedly was the big news of the day, there was another finding that I thought was of interest:

"While some employers will offer insurance for the first time, because of new access to insurance plans, other small employers will drop coverage because paying a penalty to the government will be less expensive than actually offering coverage to their employees..."

Patricia Murphy, The Capitolist, November 16, 2009

For purposes of reference, the current employer mandate features in the House bill are that employers must provide insurance or pay a penalty of up to 8% of their total payroll. Companies with total payrolls under $500,000 are exempt, and the penalty to phased in for businesses with payrolls up to $750,000. Businesses with ten or fewer employees get tax credits to help provide coverage. (Erica Werner and Ricardo Alonso-Zaldivar, Associated Press, Novemebr 7, 2009)

I’m not a small business, but I hope I might be excused for trying, on occasion, to think like one. And if I’m a small business, my decision to offering a health care package probably depends on the type of employees I’m trying to hire and keep. If I need highly educated or technically skilled workers, employees who command higher levels of salary, I’m probably going to provide the benefit. I’ll do so simply because this is the best way to recruit the highly select staff that I need, in order to stay competitive and continue to profit, and I’ll probably continue to do so regardless of the presence or absence of any kind of government mandate.

But I would argue that it’s not these highly sought-after employees that are the focus of health care reform. The currently uninsured employees we’re really worried about are, by and large, those who are essentially unskilled or hourly workers employed by either a small business or a large corporate retailer. These are people who are relatively easy to hire and easy to replace, and there seems to be a ready supply of them. The market impetus to provide insurance for them simply does not exist. This seems especially true in the midst of a recession.

So here’s my decision point as a business owner. Let’s pretend I’ve got twenty employees and a payroll of a million dollars. The government is going to require me to either provide insurance to my employees or pay a fine. It’s uncertain if I will be required to provide a full benefit to the employee or if the employee will cost-share, if I will be required to provide single person or family coverage, or the limits of coverage included within the benefits package. So for purposes of my calculation, I’ve taken the annual cost of my own individual “real-life” family policy ($16,230, of which the employer pays roughly $9,890) as a baseline. (Granted, it’s a pretty good policy, but certainly not the equivalent of the “high-value” polices subject to taxation in the current Senate version of the health care bill.)

Let’s say my company has ten employees. For my workers, the total cost of coverage will be $98,900. This compares with a penalty of 8% of payroll, or $80,000. The disparity between the fine and the premiums get larger as the number of employees rises. For example, if I have fifteen employees my cost is 148,350, and the differential is $68,350; if I have twenty employees, the numbers are $197,800 and $117,800, respectively.

So if the two obvious choices are to pay a penalty to the government or provide health insurance to my employees, I might certainly choose the less costly option. I might be even more prone to do so if I know that there are expansions of Medicaid or other subsidies to help my lower-paid employees buy insurance on their own. But there’s a third choice as well. I could decide that health insurance is an important benefit, and make up the difference between the premiums and penalties by either tightening my worker’s wages and taking the difference out of their salaries, or by letting a few go so the remainder can have their benefit. Neither of these are good choices.

Given this analysis, why would any business actually want to provide health insurance for their employees? Some large corporations such as Wal-Mart have come out in favor of employer mandates as a way to level the playing field and eliminate the competitive advantage held by companies that do not offer insurance. One might be forgivien for wondering if this support is real or simply a response to the knowledge that the train is roaring down the tracks and it's best to be on board, but the support is there nonethless. Advocates can also point to the State of Massachusetts, where employer mandates within their 2006 overhaul of health care did extract compliance from the vast majority of affected employers. (To be fair, the employer requirements were less stringent than as proposed in the current House bill, but so too were the proposed fines.) It remains to be seen if the public spirit shown by employers in the Bay State is shared throughout the country. One hopes for the best, but has unfortunately come to expect the worst.

So what’s the solution? The goal should be for businesses to opt to provide health insurance, not be forced to do so. But if employer mandates are the way to go, it would make sense to raise the penalty to an amount equivalent to that of the health insurance itself in order to eliminate non-compliance as a cost-saving choice. But much better, I think, to either rely fully on an individual mandate with generous subsidies to truly make insurance affordable (I remain desperately troubled by the idea that a family, even with a subsidy, should be required to buy insurance instead of using the funds on other needs), or to accept that the best and most cost-efficient way to solve the problem is simply to establish a baseline level of benefit for all Americans.

(Author's Note: When I originally put this note down on paper, I was using an Associated Press article as a reference. This morning, I was flipping through the news and found another AP article by David Lieb about small businesses dropping health care coverage. This article said:

"Both the House and Senate versions would offer temporary tax credits to offset a portion of the health insurance costs for businesses with fewer than 25 employees and average wages of less than $40,000...

Legislation passed by the House would impose a tax penalty on businesses with payrolls of more than $500,000 that don't offer health insurance or fail to pay at least 72.5 percent of the premium costs for a health plan with federally mandated benefits."

Granted, the differences in the provisions may seem minor, but they are differences nonetheless. So is it any wonder that nobody really understands what's going on?)

Tuesday, November 17, 2009

A report by the Centers for Medicare and Medicaid Services sent Democratic staffers scrambling over the weekend after the 31-page study revealed potentially damaging findings about the cost and coverage of the health care bill passed by the House of Representatives Saturday night. The report said, among other things, that rather than cutting costs, the bill would increase them by $289 billion over 10 years…

…the analysis from CMS's chief actuary, Richard Foster, found that the House bill will achieve its primary goal of significantly helping uninsured Americans by providing new access to affordable health insurance. However, Foster also warns that the expansion will come at a cost to the federal deficit, which will likely increase, and to seniors, who could lose access to some of their own doctors under the plan as cuts to Medicare force some providers out of the market.

Patricia Murphy, The Capitolist, November 16, 2009

I’ve always thought that out of every relationship, good or bad, you find something of value. Originally this thought came to me over an eel roll, when I recognized that were it not for being totally tossed over by a certain dark-haired girl, I’d still not know the joys of sushi, nor have anything but a passing acquaintance with female cosmetic paraphernalia such as the eyelash curler. (Such knowledge has served me well in understanding of the makeup toolkit of my bride.) And so I must thank the worst boss I ever had for at least introducing me to the following equation, one which effectively summarizes the entire problem of any health care system.

Access x Quality = Cost

(Access is the number of people who have entry into the health care system, while quality represents the number of services provided. Cost is, well, cost.)

Given that this equation is true…and while I could go into excruciatingly painful details as to why, just for the moment accept that it is…is the recent report by the Center for Medicaid Services really a surprise? You increase health care access to an unrestricted level of services, and costs go up. You could have seen this coming a mile away.

It seems to me that the fact that this report is somehow startling or controversial is simply because nobody wants to make any hard choices. Hard choices require hard thought, which is anathema to our increasingly polarized, sound-bite democracy. (One wonders if Henry Clay would have succeeded in holding the Union together given the current media frenzy.) The hard choice here is to figure out what we really want. We can’t have increased access to care, increased services provided, and cost containment. You can have increased access or quality of care, but only at increased cost. You can lower costs, but only at the expense of denying people access to the system or by restricting benefits.

My suggestion: Policymakers should listen en masse to the fifth cut on Meat Loaf’s legendary Bat Out of Hell.

Sunday, November 15, 2009

I have come to the conclusion that America is the most bowel-focused nation in the world. Scholars of health beliefs, those who put together models for the purpose of enlightening the masses and acquiring tenure…I think I got that backwards…may be able to prove that this is not true. Perhaps they have done surveys of non-Western cultures, cultures in which bowels are simply part of Tao, that they ebb and flow as a river. Perhaps they are considered a sign of karma, a symbol of regeneration as everything that goes in comes back out once again. Perhaps they are mere entrails, things to be tolerated as part of this worldly purgatory we know as earth. Perhaps I hold this mistaken belief because, by accident of fate, Northeast Florida and East Central Kansas are uniquely bowel-conscious, and that these regions are joined in some mystical fashion by the good offices of St. Bonaventura (the patron saint of intestinal disorders). Perhaps there’s grant funding out there for me to find out.

I have come to this conclusion because I have recently fallen victim to the same obsession. This is a direct result of the ED “swing shift.” One of these shifts goes from 5 PM to 1 AM. While that’s no problem for night owls like me (everyone who knows me understands that I’m essentially non-functional before the day hits double digits), it does mean that by the time you get home, eat, wind down, and try to go to bed it’s often pushing three o’clock. It doesn’t help that I do everything the sleep hygiene articles say not to do, including using the bedroom as a platform for television viewing. It’s in the effort to lull myself to sleep that I’ve discovered the late-night world of the colonic infomercial.

The best of the bunch, and the one that really captured my attention, featured a “scientist” being interviewed by “serious, skeptical journalists” before a “live studio audience” drawn to the show by their “interest in health” to hear “what doctors don’t want you to know.” (In fairness, the audience did appear to be alive, as evidenced by the applause they dispensed at regular intervals when the camera cut away to them after a particularly profound pontification.) The highlight of the show was where he showed a picture of what was claimed to have emerged from his colon after use of his cleansing elixir. It was a mass shaped in roughly a semicircle, a dark black serpentine creation that appeared frightened to see the light of day. And that night, and for nights thereafter, I mused upon this picture. I was fascinated by the question of how he got it to come out in one piece like that, and I was absorbed in wondering how and why he would chose to fish it out of its watery grave. (There actually is a third question involved…if it did not come out in one piece, how did it get its shape…but we’re really not going there at all).

(Interestingly, my late-night viewing habits have also resulted in a fixation with the work of Edward R. Murrow after happily watching “Good Night and Good Luck” on the movie channel for what has to be the fourteenth time. I wonder how he would have covered the issue of colonic hygiene on the renowned “See It Now”:

“We don’t eat fiber, our fruit intake is low, and our sense of fullness is exceeded only by our sense of seeming self-satisfaction. How that can happen in a land where nutrition is plenty, ripe for the taking? Murrow and Friendly can see no answer but in our own internal Harvest of Shame. And as we consider our nation’s colonic health, we find it true that, as Cassius said, “The fault, dear Brutus, is not in the stars, but in ourselves.”)

I try very hard not to hold myself on a higher plane than my patients. (Well, okay, sometimes I do, especially when the ED patient‘s chief complaint is “Been sick, honey, been sick since the Korean War.” First patient I ever saw in my residency. True story.) But for me, bowel movements are simply one of the less tasteful functions of life, and to consider them an object of inspection and contemplation is just another sign that somebody needs to get a life. As one of my nursing colleagues put it, “Bowel movements are a necessary evil, not an object of fascination.”

I can still vividly recall the dialogue with one the first patients I saw with a bowel complaint while working at the University Of Florida:

Q: “Any problems with your bowels?”

A: “Doctor, I had a BM this morning. It was loose, not like my usual ones that are big. There were just some little pieces that looked like a rabbit. It was floating, so I poked it with a stick and it came back up. I called the ambulance. Does that mean anything? I knew you’d want to see it, so I brought it in with me. It’s in the baggie in my purse. Do you want to see it? ”

In the interest of science, there is an answer to the question (two answers, actually). The first is that stools float when there is a lot of undigested fat in them. The second is that I have no desire to touch, let alone look in your purse, and that I will trust your description of the malodorous event without feeling any need whatsoever to conduct any further investigation.

So what happens when the person with irregularity (polite term) comes into the ED? Most of the time we take an x-ray to demonstrate that there is in fact stool in the colon, and that there are no signs of bowel obstruction. (Every scenario has an ED nightmare we try to avoid, and writing off an obstruction as constipation is the risk element here.) Back when x-rays were printed out on acetate films, you could hand-carry the snapshot up to the patient, hold the film up the light, and show them the pebbly cylinders that go up, around, and down in a reasonable imitation of a tuba. Now that everything is digital and the films can’t be lifted from the computer screen, patients just have to trust you when you tell them that they’re really full of…it. (Which reminds me of several jokes that I can’t tell you.)

Then there’s therapy. The United States is an action-oriented society, and when we want our bowels to move we want them to move yesterday. Traditional stool softeners, such as fiber, fruits, and increasing physical activity, do not fit our lifestyle. So we want powerful agents, and lots of them; agents that let us know they’re working not just through the production of the desired product, but through the suffering that lets us know we’re cleansing both the bowel and the soul.

So my prescription for those who want action, and lots of it, is a preparation called Go-Lytely. It comes in a gallon jug, which more than satisfies the American desire to supersize everything in sight. (Including the output.) This solution acts by drawing more fluid into the bowels through the process of osmosis. As fluid enters the colon it not only helps to soften the stools, but the resulting distension of the bowel lumen stimulates peristalsis to help expel the intestinal contents. (Got that? There's going to be a quiz.)

Personally, I think the brand name Go-Lytely represents one of the most creative marketing ploys ever unveiled on the face of this earth. Go-Lytely does no such thing. The person who takes it goes heavily, goes forcefully, and goes quickly in an eruptive fashion reminiscent of Mt. St. Helens (or, if you prefer a classical analogy, like Vesuvius). From what I’m told, it’s a miserable few hours. On the other hand, after the potion has done it’s duty, I understand there’s a sense of completion, a lightness of being, and state of happy exhaustion like that which overtakes one who’s done a good day’s work.

I may need to try this someday, especially as I push closer to fifty and the inevitable colonoscopy begins to rear (no pun intended) it’s head. But I’m honestly still working up to it, partially because I dislike pain, partially because I’m not sure I’ve got enough reading material to peruse while the vile agent does it’s work, and partially because I fear I’ll end up like the last excreting Kansan who made national news (“Kansas Police: Woman Pried From Boyfriend's Toilet After Sitting on It for 2 Years,” Associated Press, March 12, 2008.)

Saturday, November 14, 2009

I am The Child, as commonly referred to on my dad`s blog. I am now twelve, and have gained permission to write on my dad`s blog. I promise that this blog will keep you entertained through the times. This column shall contain such myriad subjects as Candy, Neopets, puppies, yo-yo tricks, and…..

Um, this guy.-------

To start with, villain comparisons. This will list my favorite bad guys of all time, and their rating from 1 to 10.

Sepulchere: Found in the game DragonFable, this bad boy carries a doom blade and has a penchant for destruction. He also tries to rule the earth, but it doesn`t seem to work out, now does it?

Evil Rating: 9 out of ten. Who can resist a DOOM-blade wielding doom knight?

Drakkath: Sepulchere`s evil minion in DragonFable, and his slayer in Adventure Quest Worlds, this chaos lord-in-training never knew he was going to be his master`s killer!

Evil rating (normal): 4 out of ten. Just a worthless pile of scraps, really.Evil rating (chaos): 10 out of ten. The chaos powers he suddenly gets are AWESOME. I mean, he beat the lord of evil himself.

Gravelyn: The daughter of Sepulchere, and also his best kept secret, Gravelyn is only a girl, but she vows to finish what her father started after Chaos Drakkath is gone!

Evil rating: 7 out of ten. Just a girl, but not a bad evil ruler.

Gnats: Blasted things! Can`t they just bug someone else for once?

Evil rating: 8 out of ten. I HATE GNATS!

Zorbak: The all-mighty Moglin wizard himself, creator of the dreaded Undead Kitten! Brothers with the dreaded Kabroz, who just hate each other. Oh, the irony.

Evil rating: 6 out of ten. He`s so narcissistic. Only cares about his little blue self. Sheesh.

Xan: An insane pyromancer, wanting to torch stuff for no apparent reason. And what`s with the flaming skull? That`s overkill. But he DOES have cool fire powers.

Evil rating: 8 out of ten. He`s powerful, and pretty cool too.

Sir Malifact: A cursed knight, he fell under a dark spell. In return for great power, he became a doom knight bent on destruction! Very powerful and dangerous.

Evil rating: 7 out of ten. He used to be a good guy, you know.

Twig: The EVIL moglin who loves fish and ice cream. Has a dreaded ice cream blast, and can summon whales. Very stupid, but dangerous. Keep your distance.

Evil rating: 10 out of ten. He`s awesome. Need I say more?

Deady: The most powerful evil ever, he comes from the planet Necros, which he blew up. Very, well, deadly. Anger courses through his stuffed body.

Evil rating: 17 out of ten. The awesomest thing since Adventure Quest Worlds!

Friday, November 13, 2009

Mr. Baskin came in yesterday with a mass in his neck. He’s 42 years old, smokes a pack of cigarettes each day, and drinks a beer three to four times a week. It’s getting harder for him to swallow. He works hard for a living as a laborer and tends bar part-time to make ends meet. He has no insurance and has yet to see a doctor for this. He’s not eating and has lost twenty pounds over the last year. He’s got a large, rock-hard growth under the skin on the left side of his neck. It’s lumpy, irregular, and fixed to the underlying tissue. Looking into his mouth you see that something under the skin is trying to push his left tonsil out of place. Everything screams bad. I walk out of the room and look at the nurse, who has seen the same things. “He’s going to die, isn’t he?” she asks as a statement of fact. And because his exam is what it is, and because one of the prime rules of emergency medicine is “Nice people get bad disease; dirtballs live forever,” I simply look back at her and nod.

If you have insurance, what I do is arrange an outpatient CT-guided needle biopsy of your neck mass by radiology, and set you up to follow-up a few days after the procedure with an ENT for the results. If you’re uninsured, I tell you that at our hospital we care for anyone regardless of money, and admit you to have the procedure done so you don’t fall through the cracks of the system. And either way I have to tell you, a person who I’ve just met and who doesn’t have any reason to know or trust me, about the thing on your neck. I tell you I can’t be sure exactly what it is. It might be some infection or some glands might be inflamed, or it might be a growth of some kind like a tumor. I explain to you that the best way to find out is to have someone take a piece out of it and look at it under the microscope. You don’t understand, but then you do. Your eyes get wide, and when I ask if you have any questions you shake your head for no reason other than something to do.

I have no idea how health care reform would affect him. I have no idea if his employer would carry insurance or opt to pay a fine. I have no idea if he would opt to take the subsidy to buy insurance or choose to pay a fine. I have no idea if he even works for a salary or works for cash. I have no idea if he could have a doctor to see him weeks or months ago no matter what kind of coverage he has. And in the end, it really doesn’t matter. First he’s going to undergo an operation, to be followed by radiation therapy which will dry out his mouth and cause painful ulcerations. Later, when the cancer comes back as they always do, he’ll have a laryngectomy and use an artificial voice box. Over time he’ll be unable to swallow and need a tube in his stomach for food and water, and the only thing he'll be able to put in his mouth are soft plastic swabs saturated with lemon-flavored glycerin solution and an occasional ice chip. And despite all this, the best care anyone has to offer, he’s still going to die.

Health care has very little to do with policy and politics and insurance plans.

Health care is a 42 year old man who’s going to suffer and die and you can’t do a damn thing about it.

Wednesday, November 11, 2009

I’ve had people ask me from time to time what doctors actually talk about in the ED. I think the assumption is that, just like on television, we spend most of our time either talking about difficult cases, weighing critical medical decisions, or discussing relationships. The truth is much, much stranger than you ever thought.

Here’s what passes for intellectual conversation one day last week. One of my colleagues was trying to dictate the medical record of a patient with a nosebleed. Just for the record, nosebleeds (“epistaxis,” from the Greek meaning “really disgusting”) are one of the least favorite things to care for in the ED. I don’t know anyone who thinks it’s an interesting clinical challenge, and I think it’s because nosebleed’s don’t just bleed. They bleed in a particularly unpleasant fashion. Blood by itself is really pretty innocuous...a little thicker than water, it has a little sheen to look at it and slickness to the touch, but you get it on your gloves and you move on. (If fact, in some cases of vaginal bleeding you’ll intentionally break up a blood clot with your fingers to look for fetal tissues suggesting a miscarriage.) With a nosebleed, however, you get blood mixed with snot (“mucus,” from the Latin “also disgusting”) which results in a product of varying shades, the consistency of snail traces, and a tendency to stick to everything worse than internists on old people (there’s a reason that specialists in general internal medicine are known as “fleas”). Add to it that when this stuff comes out of the nose, it either flows down the back of the throat and results in gagging and occasional retching of the nasal blood and mucous plus stomach contents, or (if you’re in just the right place) it comes out the front, punctuated with sneezes seemingly designed to cause maximum damage to the physician, who is inevitably standing in front of the patient trying to see where the bleeding’s coming from at that exact moment.

Treatment just adds to the fun. Fortunately, the bleeding often stops on it’s own. Rarely you’ll be able to see the bleeding spot along the nasal septum and cauterize it with silver nitrate. More severe bleeding comes from the back of the nasal cavity, and can’t be seen by the physician without the special tools and toys of the ENT specialist. So to get the bleeding to stop, the ED doc goes on a fishing expedition which essentially consists of jamming things…pieces of foam, plastic balloons…of increasing discomfort into the nose until the bleeding stops. And you’re doing this in the face of continued hemomucoid (“blood and pus” from the Arabic, “that’s bound to ruin your shirt”) expulsions directly towards the operator, who has to lean into the line of fire to see what he or she is doing.

At this point, the patient will be in pain (it hurts to have stuff jammed into your nose), and will feel short of breath because they can now use only one nasal passage instead of the requisite two. They don’t like you very much for what you did, and you’re not too enamored of them for making you do it. Hopefully, though, the bleeding will stop. If it does, you call the ENT and arrange follow-up for the next day, because if someone’s going to pull that stuff out of the nose and make it bleed again it sure isn’t gonna be you. If it doesn’t, you drag the ENT out of bed. (To be fair, I will say that ENT physicians so rarely have to come to the ED that when they do, they actually have a pretty good attitude about it. The chance for them to do something acute makes them feel like they’re a golden retriever and you’ve just thrown them a new red rubber ball.)

So anyway, the other doctor is trying to dictate this chart and is trying to figure out the right adjectives to describe the nosebleed. This got us started on all the different adjectives that can be used to describe bodily fluids and the ways they emerge from the body. This became a large-scale discussion involving the entire health care team in a management-friendly collaborative process. The only rule was that it had to be an adjective that you might actually hear used, not something like “paralleling the national debt” to describe a volume of fluid. (Please note that we’re talking adjectives here. The fluids themselves are nouns. You can combine two nouns to make it an adjective…for example, a mixture of mucus and pus can be described as mucopustular… but we thought that was cheating.)

At the end of the day, we decided that there were really four categories we could use to describe bodily fluids:

Quality: Clear, discolored, purulent, creamy, thick, viscous, foamy, frothy, foul-smelling, feculent, phlegmatic, gooey. (I would personally never use the latter term, because it would permanently ruin Starburst and Japanese Rice Candies and Jujyfruits for me for life. But I actually know a physician who uses that term…copiously.)

Method: Pulsatile, spurting, projective, explosive.

Taking these general categories, one can mix and match to describe the clinical fluid of their choice. (I actually started to write some examples here, but as I did I began to lose my appetite. I’ll let you string together some examples of your own and you’ll get the general idea. “Feculent,” “copious,” and “explosive” is particularly queasy combination.)

In my continuing quest for medical immortality, I would like this system to be known as the “Rodenberg-Other People Adjectival Classification of Bodily Fluids (ROPA-CBF).” I look forward to it’s immediate inclusion in curricula everywhere. And thank you for your support.

Tuesday, November 10, 2009

The recent passage of the House of Representatives version of health care reform has got me thinking about the clown cars at the circus. (And no, the joke is not what you’re thinking. That one is waaaay too easy, and I like to feel like I’ve worked for my laughs. Besides, that’s not really a joke, but merely a statement of fact, just like I’ve heard it said that the mother-in-law joke is not really a joke, but a very serious question.) Thoughts of health care reform brought me to the circus because I always wondered who was driving the car. With so many clowns packed into such a small space, there seemed to be no way that a single clown had enough space to work all the controls. And while it seems to be obvious who’s driving health care reform, and who’s trying to stand in its way, it seems much less plain who actually drives the health care system.

(I think the other, subconscious influence on me might have been that I always seem to have a Schoolhouse Rock song percolating about in my head, and lately its’ been “Three Ring Government.” Schoolhouse Rock is why I also know that interjections show EXCITEMENT or EMOTION and are usually set apart from a sentence by an exclamation point, or by a comma when the feeling’s not as strong. It’s also why I know that legislative bills often wander around the Halls of Congress on their little legs in a state of semi-permanent depression.)

(Incidentally, in the course of writing this blog I also did some research into the history of the Clown Car. It turns out that the gag was first performed at the Cole Brother’s Circus in the 1950’s. Opinions vary on how it’s done. Most references say that the car parks over a trapdoor in the floor of the ring that’s covered with hay or straw, and that the wild actions of the disgorged clowns distract the audience from looking down. Others describe a hollow shell with ledges and grab-ons that allow the clowns to hold on and fit themselves in the car. But what I found more interesting was that the term “clown car” is now used to refer to a particularly fertile woman, such as the “Octo-Mom.” No comment needed, I think.)

Under most circumstances, the question of who’s in charge is actually a pretty easy one. It just depends on who you ask and who’s the villain de jour. The folks driving the car can be the evil insurance companies who charge high premiums for great profit and little return. It might be the government who provides too many benefits, too few benefits, or not enough for me and too many for you. It might be lawyers that force doctors to raise costs and shy away from complicated patients by practicing defensive medicine. (I’m still trying to figure out exactly how terms like 4-3, Zone, and Cover 2 apply to clinical practice.) It might be doctors who shun the care the uninsured to line their own pockets. It might be the administrators whose very existence depends on the proliferation of paperwork that takes time and resources away from medical care. It might be the bean counters for whom patients and medical staff are nothing more than cost centers, and who worship at the Altar of Profit, or at Least Solvency, to the idol of the Third-Party Payer. It might be drug companies and makers of medical devices, who coax doctors to prescribe expensive medications and cajole consumers with slick television ads. It might be unscrupulous health care providers and agents fraudulently milking the system. It might be societal expectations themselves that place an emphasis on the use of technology rather than thought and reason, assumptions that demand immediate satisfaction and flawless performance in an inherently inexact art. (I actually have no problem buying into the latter rationale. At a very basic level, I believe that our attitudes towards health are driven not by a particular individual or institution, but reflect, for better or worse, what we expect of society as a whole.)

But figuring out who’s in charge of the health care system is more than an exercise in blame. Thinking hard about the issue rather than relying on the blame game is key to determining where the most effective interventions within the system might be.

A number of years ago I did some part-time work for hospitals as a physician documentation consultant. In essence, my job was to remind doctors to actually write down on the chart the things they were thinking. Physicians work with a lot of commonly understood but unstated assumptions about patient care. For example, if we say that a patient has come to the ED complaining of pressure-like chest pain and shortness of breath on exertion, virtually every ED doc will have the same three or four things on his mental short list of likely causes. But because these thoughts are a given in daily use, we tend not to write things down so there’s no track record of the thought process nor of the work that goes into the cognitive part of care. Entering these thoughts within the medical record provides a much clearer picture of care for utilization review, quality improvement, physician profiling, and risk management activities.

While I’d like to think these are good and valued goals in their own right, the reason I got paid for doing this is because hospital reimbursement Medicare Part A is based on something called a Diagnosis Related Group (DRG). A DRG is a group of diagnosis within the same organ system that share a similar intensity in the use of hospital resources, and therefore are reimbursed at the same level regardless of actual cost to the hospital. The hospital that provides care at less cost than the DRG will reimburse makes money; the facility whose costs exceed the DRG payment suffers a loss.

DRG assignment is based on review of the medical record for the physician’s documentation of the principal diagnosis (the main reason the patient was admitted) and notation of any accompanying complex medical conditions (comorbidities) or complications of care which can drive up the intensity of the provided hospital services. Successfully maximizing reimbursement requires the physician, and no one else, to fully and completely document the clinical status of the patient in the medical record. For example, clinicians are well aware that pneumonia in nursing home patients (especially those with swallowing difficulties after a stroke or who feeding tubes in place) is often due to aspiration of stomach contents into the lungs. Patients with these kinds of pneumonias often stay in the hospital longer, and have more complex medical issues, than other patients with pneumonia from a different cause. But if all you write down in the medical record is a diagnosis of “pneumonia,” the hospital is reimbursed a set amount regardless of the cause. Of you take a further step and document that the patient has “aspiration pneumonia,” payment increases. And if you also note in the record that the patient has concomitant chronic renal failure or uncontrolled diabetes, reimbursement rises again. The key is that the physician has to write down what’s going on. (Those of you “in the know” will recognize that this is a slightly dated and very simplistic explanation of the system, but please bear with me for the sake of argument.)

But what came to me as I was doing this work is that despite the many outside interlopers nibbling at their heels, it seemed like from a day-to-day, operational view, physicians still actually ran the health care system. In the very narrow sense of the work I did, physician documentation drove reimbursement. But what drove the costs was the process of establishing the diagnosis and providing care, all of which are under the expert control of the physician. And I think this concept of the doctor in charge plays out in a larger sense as well. It’s the physician who provides an entry point into the health care system through the office or clinic. It’s the physician who provides the assessment, orders tests, requests consultations, and order drugs and other treatments for acute or chronic medical conditions. It’s the physician who has to balance clinical realities, resource management, consumer demands, and societal expectations while keeping the patient’s welfare first in mind. It’s the physician’s actions (or lack thereof) which drive the medicolegal system. And while physicians are unquestionably subject to, and necessarily react to, all the outside influences upon their practice, the fact remains that nothing gets done, care is not provided, costs are not incurred, paperwork is not completed, without the doctor starting the chain of events.

(I should note that I believe this not because I happen to have an MD after my name, but because it makes intuitive sense. Nothing gets done in health care without a physician either ordering a test or treatment or passively consenting to the demands of others. And as far as the MD goes, I’m of the belief that outside of the hospital, the abbreviation rarely needs to be unveiled. The only indication I have of my degree in the house…my diplomas are somewhere in the garage, because the Residential Cat isn’t easily impressed and The Child considers my educational achievements as minimal compensation for the fact that I have not memorized the plot of every episode of “Chowder” ever aired…is a framed poem called “My Daddy, MD” whose first verse reads, “Whenever Daddy signs his name he always signs MD; so everyone will know, that he belongs to me.” Okay, it’s syrupy, but I like it. Yet I thought it was well over the top…or under the ground...when I was visiting a cemetery once to find that a head stone was engraved with “Richard Barber, MD.” I would think at that point, it probably doesn’t matter. Does heaven really have special, close-in parking lots for doctors?)

So if physicians are driving the clown car, are they necessarily the cause of this mess we call health care in America? I really don’t think so. Driving the clown car over the trap door is probably the most crucial part of pulling off the gag, and the driver has to be able to do his job to the best of his ability despite all the hangers-on who want in on the show. And while the doctor may drive the car, the car itself is provided by the circus, and once the door is open the success of the act depends on the mercy of the rest of the clowns.

So it seems to me that if we really want to reform health care, we need to concentrate on the role of the physician. Here’s an example. I recently read a study that said that only 20% of physicians in the US will accept Medicaid patient into their practice by choice. Another 20% refuse to do so. The remaining 60% see Medicaid patients not by choice, but when they have to, such as when being on call at a hospital. We already know that it’s difficult for Medicaid patients to get into physician’s offices. While it’s true that expanding Medicaid gets more patients “coverage,” what makes anyone think that simply expanding Medicaid means more patients will actually get to see a physician? Or that physicians will flock to see patients on “public option” programs with undefined reimbursement rates, especially when whatever revenue the physician makes from these is offset by higher taxes and by cuts in Medicare rates?

I recognize that this runs very close to the border of saying that doctors are nothing but mercenaries. But if any of us running a small business had widgets to sell, and one group of customers were willing to pay a higher price for the widgets, wouldn’t you preferentially sell to the higher-paying group? Of course you would, and you’d be entirely within your rights to do so. And until we abandon any vestige of the status quo, put all physicians on salary, and have a single payer system, that is the way it will continue to be. (That being said, I think most physicians recognize that part of their charge is to help those in need. I even once heard a cardiologist I personally dislike as a human being…and referring to him as "human" is pushing it…take another doctor to task for refusing an uninsured consult in the hospital. “Ten percent of everything we do ought to be for free," he said. "It’s not like you don’t have food or your kid’s not going to college.” However, there is a world of difference between giving away 10% of your work…your “societal tithe,” as it were…and greater amounts. There are some studies that show ED physicians often give away over half the care they provide. I’d be quite happy to have that time, and money, back.)

So it seems to me that if we really want to achieve health care reform within the current context…and that includes not only expanding insurance coverage, but also getting patients the care they need…we should focus less on the payment plans and more on the physician. We need to find ways to get patients into the physician offices, and to make sure they get the care they need. Unfortunately the simple solutions are not very helpful. For example, I’ve heard people say that physicians should be required to accept Medicaid or unfunded patients into their practice as a requirement of licensure. But how exactly does that work? The burden will clearly fall more on primary care physicians than specialists, which is inherently unequal. And if we already have an epidemic of medical school graduates opting out of primary care to go into high-technology, high-revenue, stable lifestyle specialties, how will this practice impact care in the long run? And enforcement seems to be a problem as well. Will there be “financial police” to audit doctor’s office and decide if they’ve seen enough Medicaid patients or not? And while we might be able to entice physicians by raising reimbursement rates for patients on public assistance, what does that do to the goal of controling costs?

Crafting real solutions based on the key role of the physician requires more than a knee-jerk reaction. It needs to include a realistic assessment of why, despite the strong tradition of service to all, physicians choose to restrict their practices to certain patient groups. (There is more…a lot more…in play than just money.) It needs to include an evaluation of if there are, in fact, enough physicians in the right places and the right specialties to achieve the overall health care goals for the nation. And it needs to identify a set of operational, clinical, and financial incentives designed to entice physicians into providing care for patients who will now be covered by new expansions of Medicaid and “public option” programs, as well as to provide care to that percentage of the population who will remain uninsured.

Sunday, November 8, 2009

I recently became aware of a physician colleague who claims to have the ability to channel those who have gone on to worlds beyond the grave. As he tells the story, he became aware of these powers somewhat gradually. Ten years ago, he started out with the idea that he would write a book about his conversations with dead celebrities. But he never seemed to make any headway until he realized that the conversations in his head were not imaginary, but real attempts by the spirits of said stars to communicate with our world. Once he let go of his scientific hesitation and accept the voices for what they are, he was able to write freely. To date he has produced five books on the topic, including, “Is There Comedy in the Afterlife?” in which Bob Hope returns for yet another NBC (Netherworld Broadcasting Company) holiday special.

I am truly fascinated by the concept of channeling, but not quite sure I can buy fully into it. While my level of spirituality tends to vary with my desires for immediate divine intervention (as I suspect does everyone’s, whether they admit it or not), I fervently hope there’s something out there beyond that which we see in the world around us and in the ether beyond the grave. But I’m not too sure about spirits channeling through any particular individual, especially when these wise spirits do things that make little sense. For example, if I’m Abraham Lincoln, I might channel through the Leader of the Free World who might actually be able to do something rather than through an auto mechanic in Cuba, Kansas. (No slight on Cuba, which is a lovely place, and only two counties north of the Ottawa County town of Minneapolis, which is the home of Rock City.) And if I’m Johnny Carson I’m going to use the best writers the afterlife can offer.

(This is my theory about the coming of the Messiah as well. When he comes…and I’m purposefully avoiding the argument of who that is or when he’ll show up…I can’t help but think his wisdom would dictate that he shows up in a major media markets on a weekday early in the news cycle. Seems to me there’d be a lot better chance of getting noticed than if he came back in a suburb of the Akron-Canton Standard Metropolitan Statistical Area. Of course, if you’re bringing the Kingdom of the Lord I suppose everyone would know in pretty short order, so maybe it doesn’t matter too much.)

But wanting to give my colleague the benefit of the doubt, I thought I’d try this channeling thing myself. So I took some quiet time and a beer, dressed in loose, comfortable clothing, turned down the lights and lit a Febreeze candle (for mood and to kill the smell of cat litter). I tried to clear my head (actually a remarkably easy task given the very few things that actually live in there) and closed my eyes, hoping for a voice from the afterlife to speak to me about those things I should know, those things that make life worthwhile, those messages I should carry with me to my friends and family so we can all live in warmth and love. And while it was hard to fully submerge my skepticism, I was gratified when I started to hear from the spirits of those who had gone before.

First Charlie Chaplin came to me. He said “

;

.."

That was heavy, and I resolved to think about this and try to apply it to my own life. But I had no chance for reflection, as Marcel Marceau came by to let me know that, “

?!"

But clearly there was a problem. Despite my best efforts, it was still hard for me to accept the reality of what was going on. The spirits of those who went before knew they had to talk to me in a language I would understand, in a religious tradition close to my heart. So Harpo Marx came to me and exclaimed, “HONKBEEP

Pumpin’ out from the lovely Isles of LangerhansComes the insulin that regulates the sugar in the bloodAnd that’s why so high I rank itAnd I’ll drop a note to thank itMay you never have a cranky pancreas!

Hey pancreas, hey pancreas, have a nice day!

- Heywood Banks, “The Pancreas Song”

Tuesday night I had two patients with the same diagnosis in adjoining rooms. In G-5 was a man in the mid-forties who had sudden onset of abdominal pain. On talking with him, the pain started suddenly that evening, and he had never had this kind of pain before. His social history noted that he drank 6-12 beers each day and had done so for years. He had never sought help for his problem, and had never been through an alcohol rehabilitation program before.

In the next pod was a slightly older gentleman who had been brought in by ambulance. His abdominal pain had started three days ago, and his use of alcohol had not dulled the pain. He had this many times before, and his old records proved that had been admitted for it on multiple occasions as well. When asked how much alcohol he drank daily, he simply groaned and said it was “too much.” That much did seem clear by the odor in the room. (Incidentally, we stopped saying that the patient has “alcohol on their breath” many years ago when the legal eagles pointed out that other beverages can give the examiner the same sensory experience, and to blame the aroma on alcohol without corroborating evidence was to possibly label the patient in error. So now we say that, “the patient has the odor commonly associated with the use of alcohol about their person,” we get a blood test to confirm it, we are uniformly right in our suspicions, and everyone seems much happier.) He had been to detox multiple times, but had always relapsed almost immediately upon his release from local residential programs.

Their shared diagnosis was pancreatitis. Pancreatitis is an inflammation of the pancreas, and it may occur for a number of reasons. People with very high serum quantities of lipids (such as cholesterol and triglycerides) are at high risk. It can also result from obstruction of pancreatic channels from gallstones or tumors, or from intra-abdominal trauma. But in the ED, chronic alcohol use is far and away the most common cause. Symptoms of pancreatitis most commonly include abdominal pain, nausea, and vomiting. Lab tests show elevations in amylase and lipase, enzymes released by damaged organ tissue. (Interestingly, in patients with chronic recurrent disease, so much pancreatic tissue is dead that there may be no enzymes left to release, and blood tests will look normal.) As the pancreas secretes enzymes responsible for digestion of carbohydrates, proteins, and fats, as well as containing cells that help to regulate blood sugar, long-term issues include malnutrition, diabetes, and severe alterations of blood chemistry. There is also a unique complication of pancreatitis known as pseudocyst formation, in which a fluid-filled cavity collects within the organ tissue. This is extremely prone to rupture and infection, resulting in even further complications. Episodes of pancreatitis are assessed using the Ranson Criteria, which was developed in Glasgow in the early 1970s. The higher the score, the greater degree of metabolic derangement and the higher the risk of complications and death. (Friends of mine from England are careful to note that the system was developed in Scotland due to the high rate of alcoholics. My Scottish friends indicate that any measurable score is simply a sign of weakness.)

The other key shared similarity between them was their financial status. Neither of them had any insurance, and so whatever care was to rendered was going to be on the taxpayer’s dollar.

But the main differences between them were equally key. From a clinical standpoint, one patient was potentially salvageable. By assuming responsibility for his own health, going to rehab and staying with the program, the first patient could halt the progression of pancreatic disease and have no further complications. The second has already demonstrated on multiple occasions his failure to follow through with the need to abstain from alcohol, had already suffered irreversible organ damage requiring intensive medical therapy, and with each admission sees his chances of continued survival fall. And from a policy standpoint, the care of the first patient benefits the entire community in keeping him active, keeping him working, and decreasing health care costs. Caring for the second not only incurs costs that should have been preventable if the patient had assumed responsibility for their own health, but also is likely to continue to place cost and resource strains upon not only the health care system, but also the social assistance sector of society as a whole.

I offer this story not only as an example of how doctors do, on occasion, actually consider their role as unwilling stewards of the taxpayer dollars, but to note that this issue of recidivism and responsibility is one of the significant “downsides” of our current health care system, and one that requires thought as we enter an era of health care reform.

The first question, of course, is why this scenario happens in the first place. Why do we not ask patients to pay a price for their actions? The easiest answer is that they already been held accountable in their loss of the good health. But I think that’s overly simplistic, because while it indicates we should feel sorry for them it doesn’t answer why we keep picking them up over and over again at our own cost.

I’m not a theologian by any means, I would speculate that one of the main reasons we continue to provide unlimited care for people despite their own worst intentions is because the religious traditions of this country hold a great belief in the power of redemption. While we may disagree on exactly how one becomes redeemed, most of us hold in common the idea at any time, one can turn away from our evil ways and resume a life of righteousness. Because this can happen at any time, and because the books are not closed on you until you leave this world for whatever comes next, there are an infinite number of chances to turn the soul back to the ways of good…or, in this case, to turn your behavior from that which jeopardizes health and inflicts costs upon others to actions which better fit our collective sense of justice.

I have no issue with the concept of allowing infinite chances for redemption. I believe that honest repentance and atonement for past evils both cleanses the soul and benefits others, and can do so right up to the moment of death. But if cost containment is a goal of health care reform, we have a hard decision to make. One choice is to accept the status quo and move on, recognizing that this portion of the battle to contain costs is necessarily lost (and will likely worsen as we see more illnesses related to behavioral-based health issues such as obesity). The second, at least in the context of justice within the health care system, is to limit the number of second chances one gets before publically-funded benefits are lost.

Don't get me wrong. I am not advocating for the withholding of care from people who genuinely need it, nor of rules or regulations which discriminate by diagnosis. But I strongly believe that if care is provided on the public purse, beneficiaries of that care must exhibit a certain level of responsibility that go with that privilege. I have no problem in the slightest offering someone free medications, rehabilitation services, educational counseling, and medical care when they are initially diagnosed with illness or injury, even if that problem is of their own making. I have no problem in continuing to provide the highest level of care when the patient has exhausted those reasonable means within their power to maintain their own health. And I recognize that there are those out there who would say this is not an issue of personal responsibility, but of cultural conflict, of prejudice (social, economic, racial, clinical, or educational), and of unclear societal expectations for individual behavior. (I actually would give some credence to the latter thought, because as a society we’ve never made it clear that there's any kind of personal accountability for your behavior as it determines the health care you receive.)

But I do have a problem in providing infinite care on the public purse for those who refuse to act responsibly in their own care. And I believe that if health care reform is to offer any expansion of publically-funded health care benefits or a “public option, that policymakers have an obligation to explore the limits of benefits within these plans and if benefits might ever be withheld through enforcing patient accountability. This is especially true if one of the goals of health care reform is to decrease the cost of care.

Granted, limiting benefits based on patient behavior is a lot easier said than done, and I hope to write more about what ideas have been tried, and the difficulties in implementing them, in a future post. In the end, there may not be a practical way to balance personal responsibility with health care reform. We may also conclude that the moral imperative for second chances outweighs the increasing costs of care. But for now, even to see our policymakers thinking about these concepts would be a start in the right direction.

Wednesday, November 4, 2009

Last week I wrote a piece regarding the controversy regarding vaccines and autism, which seems timely given the recent release of vaccine against the H1N1 "swine flu." But worries about vaccine safety are not the only reasons why people don't get their shots. One is a fear of needles, which is my own personal albatross. While it doesn’t faze me in the slightest to take a finely honed 14 gauge tubular piece of stainless steel and ram it into whichever body cavity seems appropriate at the time, the thought of an infinitely smaller 27 gauge butterfly piercing my own this hide is simply excruciating (I’m getting woozy just thinking abut it).

While this is the kind of thing one in the medical profession hopes to keep to themselves, several years ago my aichmophobia (fear of needles or pointed things) became a very public event. During my tenure as Director of Health at the Kansas Department of Health and Environment, we were having a flu shot clinic for state employees. As the down-to-earth, ground-level leader that I was, I walked among the staff, encouraging the troops and eating the cookies set out for the patients without actually doing any work. (This is called “management.”) One of the public relations folks decided it would be a good idea to take a picture of me, the State Health Guy, getting his shot as well.

Mind you, this totally irrational crazy psychiatric needle thing is not something I share on a regular basis. So I looked for an intellectual, yet remarkably cool, way out. I kept stressing that as of yet, I was not in a high-risk group, so I didn’t want the resource wasted on me when it could be used for someone more deserving. That one was pretty good, I thought. Altruistic, willing to risk his own health for that of others. But they still wanted to get a photo, so we reached a compromise. It would look like I was getting the shot, but the needle would be capped and we would rotate just enough so that nobody could see the needle cap. That way it would look real, but we’d still be saving the dose for someone else. (Still holding that “public service” line, too.)

So I rolled up my sleeve, turned three-quarters to the left, put on my requisite public servant smile, and felt the pressure against my arm. Hard. Really hard. I guess you should push hard to make it look right. The photo over, I turned around to see the nurse put the bare needle into the red sharps box.

I don’t remember a whole lot after that. I remember saying “You gave me a SHOT?”, and my eyes must have opened wide because suddenly my peripheral field of vision extended from Salina to Venus. Then I was in a wheelchair, and I was asked if I wanted to lie down. I refused. Leaders don’t lie down. They do, however, sit quietly, pant loudly, become pale and diaphoretic, and experience a full blown panic attack, the last one of which I experienced when I had to ride a roller coaster in order to impress my soon Bride-to-Be (Note to son: Dad’s not going on Space Mountain this year. Or ever).

The following year, when I went to visit the flu clinic, no shots were offered. Apparently I began hyperventilating simply walking in the door, and was directed immediately to a cot without any prior conversation.

While influenza vaccination is currently on everyone’s mind, it is only a small piece of the overall picture of immunization. Vaccination rates in this nation are not what they should be. We have national targets for immunization rates; The Healthy People 2010 Project of the United States Centers for Disease Control suggests that by the end of the decade, 80% of children should receive the minimum recommended vaccine series prior to school entry, and 90% of those adults and children at risk should receive influenza and pneumonia vaccine. (For the record, the minimum recommended vaccines for children as measured by the CDC’s National Immunization Survey is the “4:3:1:3:3” series consisting of 4 doses of diptheria, tetanus, and pertussis vaccine; 3 doses of polio vaccine; 1 doss of measles, mumps, and rubella vaccine; 3 doses of Haemophilus influenza B vaccine; and 3 doses of hepatitis B immunization.) There are also additional childhood immunizations advised to provide further protection, including those for pneumonia, chickenpox, and hepatitis A. Young women may also benefit from administration of human papilloma virus (HPV) vaccine in an effort to prevent cervical cancer.

While these are goals, they do not necessarily equate to complete protection for the population. To achieve population immunity (also known as “herd immunity,” the phenomena where protection a given segment of the population prevents disease in the group as a whole…and probably why everyone instantly understands why airline cabins are also called ‘cattle cars”), an immunization rate of 95% should be our aim (no “shot” pun intended).

Kansas had been especially concerned with childhood immunization rates, and for some time I was pleased to be part of a project known as Immunize Kansas Kids. It’s an undertaking to find out what factors make an immunization program successful in local communities and the state as a whole. While Kansas had been making solid progress in raising our immunization rates, there was still a long way to go to reach our own goal of 90% coverage for the recommended childhood vaccines.

What we found...much to our chagrin, I think…is that there is no easy answer. Some of us thought that state financing of all childhood vaccines was the key, but there is no good link between the way vaccines are financed on a statewide basis and immunization rates. Another thought was that a high reliance of the local public health department (as opposed to within physician’s offices) for vaccination depressed immunization rates, but some of our counties with the highest rates are those without any local physician. Maybe it was a function of geography and transport, but rural areas generally show higher rates than urban ones. A statewide electronic immunization registry was felt by some to be the solution, but while it makes the immunization process more accurate and consistent it doesn’t bring children in the door for shots. Access to care is likely a factor as well, but it’s hard to tell exactly how that plays out in the context of the other factors described. Of course, one of the problems with any study of this kind is that the people to talk to are those who don’t get their kids immunized on time. But since the children don’t get immunized, those families don’t appear on any record until they have to get the shots just before school, two to three years after the optimal window for care.

One thing that seems to be missing from the discussion is the potential role of prehospital EMS services in immunizing the community. While you could argue that doing preventive primary care is not part of the mission of EMS (and I’d argue back at you that any health care professional should morally be concerned with preventing the very suffering that employs you), logistically EMS is ideally suited for immunization efforts, especially in rural areas where "down time" between calls are often prolonged and where it's not cost-effective to run large-scale vaccination clinics. EMS fixed costs such as the unit, the crew, and the station are constant, and previously non-productive time can now be used as an enhanced community resource, an expanded demonstration of paramedic abilty, and even a potential driver of revenue.

That being said, the idea of EMS services, especially those that are fire-based, giving immunizations is not a new one. Many fire stations dispense flu and pneumonia shots to elders every year during the late fall. It’s a community service, there’s cash and/or Medicare reimbursement involved, you never have to leave the comfort of your work “home,” and immunizing adults plays to the comfort level of EMS staff.

But just think of what impact one could make in children, which is our real target population. The mobility of EMS equipment and expertise means that the vaccines can be taken to where the children are, including disadvantaged parts of the community or labor camps in rural areas. EMS is often not perceived as intrusive or punitive in the same fashion as law enforcement, so access to children of migrants or those here under other circumstances may be enhanced. (While the issue of immigration is beyond this discussion, I do agree with Arkansas Gov. Mike Huckabee who noted, in a debate about immigration reform during the last Presidential campaign, that this nation should be above punishing the children for the sins of the father.)

I would suspect that local health departments would be more than willing to work with EMS staff to expand the outreach of their immunization programs, and may in many cases be able to provide supplies and materials, or even reimbursement for services, using their own federally and state funded resources intended for those in need. Participating in such efforts also gives EMS crews more comfort in assessing and caring for children, which can only benefit the total skill set of the paramedic. Importantly, the increased level of visibility that comes with this level of community involvement reinforces the need for support of EMS services at a time when fiscal considerations are putting the industry at risk.

I hope that EMS services will use the opportunities presented by immunization efforts during this year’s influenza outbreak to expand their reach to the full spectrum of immunizations. Just don’t ask me to come by that day. And if you do, have the cot ready.